Integrating music therapy into diagnosing context of autism spectrum disorders
Candidate nr. 101 Thesis submitted in fulfilment of the requirements for the Master’s degree
University of Bergen May, 2019
Acknowledgements
I would like to thank my mentor, Xueli Tan for support and inspiration. Your guidance helped me to navigate my compass towards the right direction.
Big thanks to my friend Jelena for unlimited time, patience and support in the moments when they were most needed. Ana, thank you for revealing the secrets of English language to me.
Finally, special thanks to my wonderful family for the unselfish support and love through the years of my studies.
I dedicate this study to all children and adults who live with autism in hope that the future of diagnostics will reveal much needed insights into the complexity of human capacity within the autism.
Abstract
The purpose of this study is to explore how music therapy approaches can complement the existing diagnostic context of autism spectrum disorder (ASD). Using the integrative
literature review as methodology, the data from both medical and music therapy contexts on the subject of assessment of ASD was gathered and synthesized. The new knowledge that was generated in this way indicates that the existing diagnostic context of ASD assessment, even though psychometrically-tested for evaluating impairments of ASD, could potentially benefit from including music therapy assessment in its current structure. The properties of music therapy as a humanistic discipline can provide unique insights into the assessment and overall interpretation of ASD.
Table of contents
1 INTRODUCTION ... 7
1.1 MUSIC THERAPY AND ASD RETROSPECTIVE ... 9
1.2RESEARCH QUESTION ... 11
1.3BACKGROUND FOR THE RESEARCH QUESTION ... 11
1.4GLOSSARY OF TERMS ... 13
1.5DISPOSITION ... 13
2 METHOD AND METHODOLOGY ... 14
2.1METHODOLOGY.INTEGRATIVE LITERATURE REVIEW ... 14
2.2METHOD.CONTENT ANALYSIS ... 15
2.3HERMENEUTICS ... 16
2.4PROCEDURES ... 17
2.4.1 Collecting data about existing standardized tools for ASD evaluation (medical context) ... 17
2.4.2 Collecting data from the music therapy assessment for ASD ... 18
3 RESULTS ... 20
3.1DATA FROM THE MEDICAL CONTEXT ... 20
3.1.1 Graphical presentation of the content analysis of data from the medical context ... 21
3.1.2 Textual presentation of the content analysis of data from the medical context ... 22
3.1.3 Theoretical perspectives in the selected instruments (medical context) ... 23
3.1.4 Purpose ... 23
3.1.5 Form ... 24
3.1.6 Sources ... 25
3.1.7 Behavior ... 25
3.1.7 Psychometric value ... 30
3.2DATA FROM MUSIC THERAPY CONTEXT ... 31
3.2.1 Presentation of data from music therapy context ... 31
3.3CONTENT ANALYSIS OF THE TOOLS FROM THE MUSIC THERAPY CONTEXT ... 32
3.3.1 Graphical presentation of the content from the data from music therapy context of assessment for ASD ... 33
3.3.2 Theoretical perspectives of the instruments from the music therapy context ... 33
3.3.3 Purpose ... 35
3.3.4 Form ... 39
3.3.5 Sources ... 40
3.3.6 Domains of the behavior ... 41
3.3.7 Metrical values ... 45
3.3.8 Musical behavior ... 46
4 DISCUSSION ... 47
4.1UNDERSTANDING OF ASD ... 47
4.2EVALUATIVE DOMAINS ... 49
4.2.1 Time ... 49
4.2.2 Environment ... 50
4.2.3 Social behavior ... 52
4.2.4 Emotional behavior ... 53
4.2.5 Cognitive functioning ... 54
4.2.6 Sensory behavior ... 55
4.2.7 Communication ... 55
4.3OVERVIEW OF BOTH CONTEXTS ... 57
4.3.1 Health and wellbeing ... 58
4.3.2 Spiral of competence and circles of competence ... 58
4.3.3 Static product and dynamic process ... 59
5 CONCLUSION ... 61
REFERENCES ... 63
Without science, therapy can degenerate to the practice of superstitious ritual, in which each practitioner owes allegiance only to his or her personal myth of existence. Without art, it can lose the very humanity it seeks to examine (Feder & Feder, 1998, p. ix).
1 INTRODUCTION
The purpose of this study is to explore if music therapy assessment can complement existing diagnostic evaluation for Autism Spectrum Disorders (ASD). Music therapy is successfully used as a complementary treatment for ASD (Boster, McCarthy, & Benigno, 2017), but it is not commonly included in the diagnostic process of ASD (Wigram, 2000). For the further development of music therapy as a discipline I think that it is essential to search for ways to include music therapy as a complementary method in the diagnostic context of ASD. Music therapy as a discipline includes both natural-science and humanistic orientations (Bruscia, 2014; Waldon & Gattino, 2018). Inclusion of music therapy approaches that successfully combine medical and humanistic values could potentially enrich the final diagnostic picture by providing the medical information about the child’s level of functioning (presence of impairments) from medical professionals, and also the information about other facets of the child’s potential through music therapy assessments.
Evolution of autism
Autism spectrum disorder (ASD) is defined as “a neurodevelopmental disability characterized by impairment in social-communication skills and the presence of restricted or repetitive behaviors” (American Psychiatric Association [APA], 2013). Even though this current
definition had undergone a long historical evolution, defining autism spectrum disorder is still an ongoing process. If we look at autism through the historical lens, we can see that the first written case that reported the unusual behavior of one boy (behavior that is described
resembles impairments often found in autism) dates all the way to 18th century, where it was described as a form of madness (Haslam, 1809). Haslam (1809) described the boy as seven years old when he first met him. The boy’s mother reported that the child was developing very slowly both physically and mentally. He developed language around his fourth year but was not using it efficiently. Haslam (1809) observed that the boy had the ability to imitate, a need for social isolation, as well as a need for self-stimulation through repetitive stretching.
The term “autism” appears in the medical literature in 1911. It was introduced by the Swiss psychiatrist, Eugen Bleuler, who used this term to describe the withdrawal behavior of
children he considered to be schizophrenic (Irwin, MacSween & Kerns, 2011). “The origin of the term autistic is from Greek autos (self) and ismos (a suffix of state of action)” (Irwin et al, 2011, p. 3). This term appears again in 1943, this time in the form of the noun “autism” in an article by Austrian psychiatrist Leo Kanner (1943). In his article, Kanner (1943) presented
schizophrenia. Instead, he emphasized autism as a developmental disorder, since it is present from the beginning of life. He wrote:
While the schizophrenic tries to solve his problem by stepping out of a world of which he has been a part and with which he has been in touch, our children gradually compromise by extending causing feelers into a world in which they have been total strangers from the beginning. (Kanner, 1943, p.249)
Refrigerator mother theory and other theories of ASD
At the beginning when the word “autism” got its place in medical books, the understanding of what causes autism was influenced by psychodynamic trends in psychiatry (Irwin et al., 2011). Kanner believed that autism was caused by mothers who failed to show love and affection towards their children (Irwin et al., 2011). He presented this idea carefully in the beginning, by only mentioning the presence of a genuine lack of affection from family members, especially mothers (Kanner, 1943). Two decades later he stated his opinion on the causation of autism more clearly in one interview, where he described that parents of children with autism were so cold and that they managed to “defrost enough to produce a child” (as cited in Irwin et al., 2011, p. 4). His claim was the reason why autism was considered to be caused by “refrigerated mothers” for many decades to come (Irwin et al., 2011).
Psychoanalytic approaches to defining autism continued in 1960’s through the work of Austrian child psychologist Bruno Bettelheim. Bettelheim not only agreed with Kanner’s hypothesis about mothers, in his book The empty fortress: Infantile autism and the birth of the self (1967), he went further to compare mothers of autistic children with Nazi prison guards.
Bettelheim himself had spent the Second World War as a prisoner in concentration camps. He explained that the empty gaze often seen in children with autism is a reaction to the
negligence of parents (mothers primarily) and compared it with the look of prisoners in the camps. He suggested that autism is a condition that a child develops as a response to extreme situations such as hostilities from mothers (Bettelheim, 1967).
Medical evaluation and diagnosis
The psychoanalytic approach lost its popularity with the development of technology and the expansion of research in the field of ASD. Findings from the field of genetics indicate that the cause of ASD is multifactorial and includes both genetic and biological factors (Irwin et al., 2011). Siblings of children with ASD have a 20 - 60% higher risk of developing autism themselves (Sokol & Lahiri, 2011). The X chromosome abnormalities are found to be directly
responsible for a 1:4 gender ratio found in ASD, meaning that the statistical disproportion of ASD that affects boys is four times more than girls (Sokol & Lahiri, 2011). The female DNA that consists of two copies of X chromosomes, while male has only one copy and therefore four times higher risk of developing ASD (Sokol & Lahiri, 2011).
The roots of modern perspectives on the evaluation of behavior in ASD began in 1958, with the work of psychologist Hans Eysenck and his colleagues who opposed the psychoanalytic interpretation, and advocated for empirical-based approaches (Adams & Matson, 2016). Their collaboration led to the development of the first assessment and diagnostic tools that could be applied by all psychiatrists (Adams & Matson, 2016). The criteria were based on the direct observation of behaviors that is known nowadays as “triad of impairment” (impairments of reciprocal social interaction, verbal and non-verbal communication, and imagination) (Luteijn, Luteijn, Jackson, Volkmar & Minderaa, 2000, p. 317). However, the classification and understanding of autism is still an ongoing process. From the 1990’s, diagnostic
categorization of Pervasive Developmental Disorders (PDD) by the American Psychiatric Association (APA, 2013) and the World Health Organisation (WHO, 2017) spoke of the
“autistic continuum” and included Autistic Disorder, Asperger Disorder, Rett Disorder, and Childhood Disintegrative Disorder (Luteijn et al., 2000, p. 317). These disorders display common behaviors that were categorized as the triad of impairments (Luteijn et al., 2000).
According to the Centers for Disease Control and Prevention (CDC, n.d.), the process of evaluation of ASD occurs in two phases:
1) Developmental screening
2) Comprehensive Diagnostic Evaluation
Developmental screening is a part of standard pediatric developmental evaluation, with the purpose of targeting the children that are at risk of developing ASD.
The comprehensive diagnostic evaluation is the next step in the process after the initial
warning signs were detected (CDC, n.d.). Comprehensive diagnostic evaluation is a procedure that can include a variety of medical professions, including developmental pediatrics, child psychology, neurology, and child psychiatry (CDC, n.d.). This means that ASD is evaluated by an interdisciplinary approach within the field of medicine.
1.1 Music therapy and ASD retrospective
Music therapy as a profession started developing at the same time when the word “autism”
aspects that music therapy has on children with autism were noticed from the beginning of music therapy interventions with this particular client group (Reschke-Hernandez, 2011). In the 1940’s it was common practice for children with autism to be placed in medical
institutions, where the first music therapy treatments were organized for them (Rechke- Hernandez, 2011). The first music therapy activities that were used had a more structured form, using dance rhythms and singing exercises (Geretsegger et al., 2015). The interest in music therapy assessments for ASD grew alongside with the continual development of music therapy as a discipline since the 1940s.
Nordoff and Robbins (1968) wrote about the beneficial potential that improvised music has on children with autism. A decade later they published a book called Creative music therapy, individualized treatment for the handicapped child (Nordoff & Robbins, 1977) which illustrates the necessity to use creative, improvisational approaches to assess the behavior of children with developmental disorders. The authors included a description of the procedures they used in their assessments. Improvisational music therapy (IMT) is still a common approach in the assessment of behavior in music therapy treatment for this population (Geretsegger et al., 2015; Mössler et al., 2017).
Apart from observing the outward manifestation of ASD such as stereotypical behavior, difficulties in behavior regulation and socialization, music therapy also offers a window into the child’s inner world. The work of psychologist Daniel Stern describing the world of infants (1985) was very influential in the field of music therapy. Stern (1985, p.142) introduces the term “affective attunement” as a way in which the infant reacts to the mother’s voice and facial expressions in the infant’s early interactions with the mother. This term is adapted and used in music therapy as a technique in which music therapist is using “musical attunement”
(Schumacher, Calvet & Reimer, 2018, p. 213) when working with a child to re-create mother- infant form of early communication (Schumacher, Calvet & Reimer, 2018). The Assessment of the Quality of Relationship (AQR scale) was developed based on these theoretical grounds to measure the quality of interaction between the child and music therapist for the population with ASD (Schumacher et al., 2018).
In the past seven decades, the body of knowledge regarding the positive effects of music therapy for ASD has increased. The data from an extensive systematic review and meta- analysis conducted in 2017 supports the idea that music therapy is beneficial in addressing impairments commonly found in children with autism (Boster, McCarthy & Benigno, 2017).
The positive effect was measured in the treatment setting, as well as outside the intervention
setting and in the parent-child relationship (Boster et al., 2017). The conclusion based on the data that was collected was that this form of therapy is beneficial for children (Boster et al., 2017). However, it is essential to mention that music therapy is generally used in care-related context, and besides a few exceptions, the use of music therapy evaluation is not part of the standardized diagnostic process (Wigram, 2000).
1.2 Research question
In this master thesis I will try to answer the following research question:
How might music therapy approaches/methods complement existing standardized diagnostic tools in the medical context of evaluating children with ASD?
1.3 Background for the research question
Early detection and intervention are key elements for ASD treatment (Steiner, Goldsmith, Snow & Chawarska, 2012). This is supported from both the biological and environmental perspective. The young infants’ brains during the early phase of intensive development are more easily susceptible to interventional measures, and that some of the social codexes can be taught more successfully early on in their lives (Steiner et al., 2012). Diagnosing the child at an early age seems to be a common meeting point of both the medical professionals and the parents. From the medical perspective, early diagnosis is essential, because it opens the door for early interventions that will evidently be crucial for positive outcomes later in life
(Corsello, Akshoomoff, & Stahmer, 2012).
The process of diagnosis affects not only the child but the other family members as well.
Parents report that dealing with a suspicion about their child having ASD could cause severe problems related to stress (Osborne & Reed, 2008). The factor of stress can reflect itself in a number of different dysfunctional problems such as depression, dysphoria and general dysfunction of family dynamics (Osborne & Reed, 2008). Parents agree that early diagnosis can help with stress reduction, meaning that the tension built upon the feeling of uncertainty whether the child has ASD or not is much lower in parents who received the diagnosis within a short waiting time period, compared to the group of parents who had to wait longer (Brogan
& Knussen, 2003; Holliday, Stanley, Fodstad, & Minshawi, 2016). In consideration for the parents, having a timely closure about the child’s condition is therefore one of the main reasons for adjusting evaluation tools for early diagnosis.
The stress level can also be increased by the negative experience of communication with
and it could potentially lead to the lack of parental involvement in early intervention programs (Osborne, Mchugh, Saunders, & Reed, 2008). The role of the parent as an educator is
something that should be encouraged, since the learning process and support of a child’s development is an everyday routine for families with children diagnosed with ASD (Osborne et al., 2008).
In 2008, a study was done in the United Kingdom, in order to determine how parents perceived communication with the healthcare professionals during the diagnosing process.
The results showed that half of the parents of the preschool children participating in the study felt that the diagnosis procedure was done in a cold manner. They were left feeling poorly informed and cut off from the important information about ASD in general. They also worried that their children were not seen as unique individuals with unique potential, but that the healthcare professionals’ only focus was to find out whether or not the child has ASD (Osborne & Reed, 2008).
A similar study involving interviews with the parents to explore their perspective of their experience of the diagnostic process was completed in Sweden (Carlsson, Miniscalso, Kadesjö, & Laakso, 2016). The findings were similar to the study done in the United
Kingdom, meaning that once again, parents reported feeling alone, both during and after the process (Carlson et al., 2016). Some of the parents from the study in Sweden reported that they felt “the experts did not have a chance to see the child’s full potential since the assessment was done in the environment unfamiliar to the child” (Carlsson et al., 2016, p.
333).
Parental studies indicate that there is a need for a more thorough and child-oriented approach to complement the existing diagnostic structure in order to provide a richer and more precise evaluation about the child’s overall level of functioning. This comprehensive approach should also include an assessment of the child’s potentials and strengths. Music therapy approaches can fulfil this complementary role. Music therapy approaches to children with ASD can be described as child-led (Wigram & Lindahl Jacobsen, 2018) and autism-friendly (Begrmann, 2018). The purpose of this study is, therefore, to explore the possibility of including such approaches into existing standardized tools, so as to provide a complementary approach for a more thorough evaluation.
1.4 Glossary of terms
Music therapy - “Music therapy is a reflexive process wherein the therapist helps the client to optimize the client’s health, using various facets of music experience and the relationships formed through them as the impetus for change.” (Bruscia, 2014, p. 36). I will use this
definition in my understanding of music therapy assessment as a reflexive process, experience and relationship that has the purpose to understand the potential in child’s condition as a way of optimizing resources that are needed for change and improvement of functioning.
Music - Bruscia (2014, p. 45) defined the use of music as “music in therapy, or music as therapy”. Based on Bruscia’s (2014) definition and my personal understanding, I interpret music in music therapy assessment as a threefold dimension that can be used as a tool to help the therapist in the assessment, as a process that occurs between the child and a therapist, and as a general music experience of the assessment.
Health - My understanding of health is in alliance with the definition of World Health
Organization that defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease, or infirmity” (WHO, n.d.). In the context of the
assessment of ASD, I understand health as a twofold concept: a child can be assessed for condition described as ASD, but the child’s wellbeing can also be assessed within this condition.
ASD - stands for Autism Spectrum Disorder. When defining autism, two perspectives appear to dominate: medical and social. The first and more dominant is the medical one that defines ASD as “a neurodevelopmental disability characterized by impairment in social-
communication skills and the presence of restricted or repetitive behaviors” (American Psychiatric Association, 2013).
Autism is also defined as neurodiversity in the autistic community and by the individuals who live with this condition (Krcek, 2012). The term neurodiversity is their attempt is to advocate for the understanding of ASD as a state of being and functioning, rather than abnormality, or disability. They perceive disability to be a social construct rather than the personal experience of living with ASD (Krcek, 2012).
1.5 Disposition
In chapter 1, I present the background of my choice, the research question and explaining my current position regarding the research question. In this chapter, the most important terms
I have chosen the integrative literature review as a methodology for this study and how I have chosen to position myself as an interpretivist in this study. In this chapter, the inclusion and exclusion criteria for gathering data is presented. In chapter 3, the data that was selected will be presented accordingly to the methods described in chapter 2. In chapter 4, the data are integrated and discussed. Chapter 5 addresses the research question as well as the conclusion for this study.
2 METHOD AND METHODOLOGY
In this chapter, I will describe my approach to answering the research question and the exact scientific steps in the process of this study.
2.1 Methodology. Integrative literature review
“Reviews can attempt to integrate what others have done and said, to criticize and/ or to identify the central issues in a field” (Cooper, 1989, p.13).
This design can enable an overview of different studies from the field of ASD that as a result provide a selection of the instruments that relate to the same topic (assessment and diagnosing of ASD) and music therapy perspectives on the same topic. The thorough summarization can provide enough information about some aspects that are lacking and need further
improvement (Cooper, 1989). In this paper, the topic of assessing ASD will be analysed by integrating the body of knowledge about this process from the clinical and music therapy perspectives.
In order to answer the research question, two sets of data will be collected to present two models of assessment. Torraco (2005) points out that the integrative literature review is used for integrating knowledge from two models that can be described as competitive. The models that will be analysed present two contexts of evaluation for ASD: the medical and music therapy contexts. While my pre-understanding of these contexts is that they are
complementary rather than opposing, they can also be interpreted as competitive in a sense that the medical definition of ASD presented in chapter 1 defines the behavior of individual with ASD as an impairment (APA, 2013), whereas the individuals that are living with ASD do not see themselves as impaired, but just different from the majority (Krcek, 2012). Since music therapy assessment for ASD is client-based and child-led (Wigram & Lindahl
Jacobsen, 2018), and is also medicaly informed about what kind of impairments it needs to measure in ASD (Bergmann, 2018), this indicates that the understanding of client’s behavior
is observed from various perspectives, that include more than one orientation. Therefore, these two contexts can be both complementary and competitive.
The integrative review is a broad design that allows simultaneous inclusion of empirical and theoretical knowledge (Whittemore & Knafl, 2005). In this study, I will integrate the
knowledge from music therapy and medicine, two different disciplines, one of which is, in essence, empirically based and the other one is from the field of humanistic disciplines. In the introduction chapter, it was mentioned that existing evaluation and assessment for ASD is based on the empirical model. In music therapy assessment, other approaches, such as IMT, are used, and the assessment is based on other standards that do not include rigorous empirical testing (Chase, 2004). This is the reason why I think that integrative literature review is the design that can provide the best presentation of knowledge from these two disciplines by including data from both experimental and non-experimental research.
In order to accurately explore the idea of the potential need for integration of music therapy assessment (that will be addressed in the discussion chapter), data will be presented in form of analysis of the evaluation and selectively gathered diagnostic instruments. I will follow five research phases that are suggested by Cooper (1989):
1) Problem formulation;
2) Data collection;
3) Evaluation of data points;
4) Analysis and interpretation;
5) Presentation of results.
2.2 Method. Content analysis
1) The aim of the study is to explore how music therapy assessment can complement existing standardized diagnostic tools.
2) Selective sampling of the instruments most commonly used in diagnosing ASD will ensure that the data accurately represents the body of instruments that are currently used in the medical context. The procedure of collecting and selecting relevant data will be presented in this chapter.
3) Once they are selected, the instruments will be grouped by their common features and presented in the table. If some instruments are found to be extraordinary comparing to others in the manner they evaluate/diagnose ASD, they will also be presented. Since this study is not
content analysis of the data will be done. The content of the literature that fits the inclusion criteria is the subject of analysis in the process of this study. “Content analysis entails a systematic reading of a body of texts, images, and symbolic matter, not necessary from an author’s or user’s perspective” (Krippendorff, 2004, p. 3). Based on this definition, the content of instruments for comprehensive diagnostic evaluation for ASD will be analysed through the perspective of music therapy approaches. In order to gather and describe the selected data, it will be grouped by specific and common characteristics which in this study will be referred to as “features”. The content of the data will be further analysed through the music therapy perspectives on assessment for ASD. “Once content analyses have chosen the context within which they intend to make sense of a given text, the diversity of interpretations may well be reduced to a manageable number (Krippendorff, 2004, p.24). For the purpose of this study, it is not important to collect all the assessment and diagnostic instruments, but only those that are most commonly used. This will limit the content analysis to a manageable number of instruments whose content will be analysed.
4) The analysis and interpretation chapter will be presented through discussion. The chosen approach belongs to the qualitative discipline research that addresses the music therapy involvement in the areas of assessment, treatment, and evaluation (Brusica & Wheeler, 2016).
My position in this study can be described as the one from an interpretivist view of the current approach to ASD assessment, which is observed as a construction based on both benefits and limitations of this particular medical context.
5) The conclusion chapter will provide the insights to respond to the research question.
2.3 Hermeneutics
The philosophical theory in the study is necessary because it provides us with a lens through which we will be looking for information (Wheeler & Bruscia, 2016). It also helps to
understand what the study aims to find out regarding a particular topic it is exploring. Modern hermeneutics roots come from Ancient Greek philosophy and the idea that language serves a purpose of interpreting “non-linguistic impressions made by the things of mind” (Bowie, 2015, p. 2). Whittemore & Knafl (2005) pointed towards importance of theoretical, or philosophical perspective in the integrative reviews. I understand autism as a mind-made concept that is evolving with the increase of our knowledge on the topic. However, I think that in the very core of autism one feature is constant: it is a condition within a human being.
Hermeneutics is a system of thinking that tries to understand how “each is only posited with and by the other, just as whole cannot be thought without the single part as a member of it and
the single part cannot be thought without the whole, the sphere in which it lives ” (as cited in Bowie, 2015, p, 3). For me, the spirit of the whole is a human being that is in the center of the diagnostic structure. From my pre-understanding, based on the parental reports, the human and individualistic nature of the child as an individual is missing from the current diagnostic model. Therefore, my study could be described as hermeneutically and humanistically oriented.
2.4 Procedures
Collection of data occurred in two phases. First, I collected data for assessing and diagnosing instruments from the medical context, and in the second phase, I collected data for assessing ASD in music therapy context.
2.4.1 Collecting data about existing standardized tools for ASD evaluation (medical context)
I chose to search in the ORIA database because ORIA enables access to a variety of different databases that are relevant for terms used in the research question. They regard the fields of medicine, art, and therapy. I used “instruments for assessing and diagnosing ASD” as the key phrase for the search. Initial findings present 1658 different titles. From this vast pool of data, I have decided to do purposeful selection to ensure that the selected data can provide
maximum variation (Palinkas et al., 2015), and to ensure that the findings will represent a variety of different instruments.
In this case, I wanted to find out what are the protocols of assessing and diagnosing for ASD, meaning what specific instruments are used for this purpose. I have decided to choose
literature that can provide overall knowledge on the topic of assessment and diagnosing and that includes a pool of different instruments that are used for this purpose. Three books rich with information on assessing and diagnosing ASD were selected:
1) Volkmar, F. R., Paul, R., Rogers, S. J., Pelphrey, K. A. (Eds.) (2013), Handbook of autism and pervasive developmental disorders (3rd ed.). Hoboken, Canada: John Wiley
& Sons.
2) J. L. Matson (Ed.) (2016), Handbook of assessment and diagnosis of autism spectrum disorders. Cham, Switzerland: Springer International
3) J. L. Matson & P. Sturmey (Eds.) (2011), International handbook of autism and pervasive developmental disorders. New York, NY: Springer International.
From these books, the research was narrowed down to identify instruments that are most commonly used in assessing and diagnosing ASD. It is important to mention that majority of instruments are described in a form of protocols, or manuals, because the original instruments with the scoring system and exact questions are not in domain of information that is shared with the general public. Some of the instruments are also the property of different institutions (hospitals, universities). However, during the research, the additional data was gathered in the form of literature written by original instrument designers that contained a rich and thorough explanation of how their instruments evaluate ASD. They were coded and presented in table 1, whereas books, in general, were used for assembling theoretical knowledge that was necessary for understanding the terminology and features of selected instruments.
When sampling instruments, the following criteria were used:
1) Instruments are used as part of the standard international screening and diagnosing of ASD
2) Instruments are a part of established medical literature on ASD
3) Selection included only those instruments that address ASD impairments, rather than instruments that screen general developmental impairments
4) Only the instruments that are used for evaluation/diagnosing of children are included 5) Only the revised version of the instruments will be presented
Some exclusion criteria have also been formulated:
1) Instruments that are in experimental phase
2) Instruments that are used in biological, neurological, and genetic research, because they are not part of the standard diagnostic procedure
3) In the year 2013, the new revision of psychiatry´s Diagnostic and Statistical Manual of Mental Disorders (DSM-5) classification is combining Autistic Disorder, Asperger Disorder, Childhood Disintegrative Disorder, and Pervasive Developmental Disorder (not otherwise specified) into a single diagnosis of ASD (APA, 2013). Therefore, all the instruments that measure Asperger Disorder are excluded.
4) Older versions of revised instruments are excluded
2.4.2 Collecting data from the music therapy assessment for ASD
In the second phase of the search for data that I started in the ORIA database, I used “music therapy tools for assessing and diagnosing ASD” as the key phrase for the search. I have changed the search word “instruments” that was used in the first search phrase, because the
interest of this study is not to find out what music instruments are used, but rather what tools (scales, assessment instruments) are used in music therapy. In the majority of music therapy literature I came across during the search, the word “assessment” was used as a term that is measuring the effects of music therapy on children that are already diagnosed. I have then tried to search by using the terms “evaluating” and “screening” instead, since these terms are also used in medicine when addressing assessment for ASD. The findings were again not usable, because of the same reason. Therefore, I decided to do a selective sampling following the recommendation of Torraco (2005) about selecting the data through relationship, and similar patterns. In order to find the relationship and similar patterns between these two contexts, the first portion of selected data from the standard diagnostics needed to be analysed.
The method that I used to analyse data is content analysis. Based on this method (that will be presented in depth in chapter 3), the instruments that were selected in the first search were analysed by their common features, coded and presented in table 2. Data for music therapy diagnosing and assessment were collected based on the common features of medical instruments that were detected in the content analysis.
Since all instruments from the medical context were collected from Handbooks of ASD, I have decided to include the book by E. G. Waldon & G. Gatino (Eds.) (2018), Music therapy assessment: Theory, research, and applications, London, UK: Jessica Kingsley. Following the same procedure, I have decided to use some chapters from the book as a theoretical frame for instruments that were selected, as well as to sample individual instruments that assess ASD, so that they can be analysed in chapter 3. Seven chapters from this book were selected because they contain information about protocols and different assessment tools for ASD. The tools that will be analysed are based on the description presented in the book chapters because original instruments were not found for the same reason the originals instruments from
medical literature were not found. However, the selected book chapters were written by the original designers of music therapy tools and contain a thorough description of how these tools operate. The exception is the “Evidence-Based Analysis” (Wigram & Lindahl Jacobsen, 2018) chapter that was written and published after its designer (Tony Wigram) died. The second author wrote the chapter based on Wigram’s notes, reflections and original publications on the subject.
Two international survey studies were also included, because additional information on music therapy assessment tool for ASD were extracted from them. The results from literature search will be presented in the next chapter.
3RESULTS
Instruments that were collected to represent the medical context for assessing and diagnosing ASD will be listed and presented in the table by their common features and relationship between their main characteristics. After presentation of the first set of data from the medical context, the other set based on common features of the instruments in the first table will be presented. The other set of data is the music therapy context of assessing ASD. The selected instruments were coded by the model of lower-higher level of abstraction from the manual for content analysis that suggests that text should be analysed by determining obvious features, and that will narrow down their content to more specific information (Erlingsson &
Brysiewitcz, 2017). Findings will also be explained textually with additional theory section.
This step was necessary for understanding and integrating theoretical knowledge as an
important part of the integrative review (Cooper, 1989), because it provides an overall picture necessary for understanding of each context.
3.1 Data from the medical context
ABC- Autism Behavior Checklist (Krug, Arick, & Almond, 1980)
ADI-R Autism Diagnostic Interview-Revised (Lord, Rutter, & LeCouteur, 1994) ADOS-G- Autism Diagnostic Observation Schedule-Generic (Lord et al., 2000)
ASD-DC- Autism Spectrum Disorders- Diagnosis for Child (Matson & Gonzalez, 2007) ASEBA- The Achenbach System of Empirically Based Assessment, Preschool Forms and Profiles (Achenbach & Rescorla, 2000)
BISCUIT– Baby and Infant Screening for Children with Autism Traits- Part 1 (Matson, Boisjoli & Wilkins, 2007)
BFI- Behavior Function Inventory (Adrien et al., 2001)
BOS- Behavior Observation System (Freeman, Ritvo, Guthrie, Schroth & Ball, 1978) BSE-R- The Revised Behavior Summarized Evaluation (Barthelemy et al., 1997) CARS- Childhood Autism Rating Scale (Scholper, Reicher & Renner, 1988)
CBCQ- The Children´s Social Behavior Questionnaire (Luteijn, Jackson, Volkmar &
Mindreaa, 2000)
3DI- Developmental and Diagnostic Interview (Skuse et al., 2004).
DISCO 9- Diagnostic Interview for Social and Communication Disorders- Ninth Edition (Wing, Leekam, Libby, Gould & Larcombe, 2002)
GARS- 2- Gilliam Autism Rating Scale- Second Edition (Gilliam, 2006)
M-CHAT- Modified Checklist for Autism in Toddlers (Robins, Fein, Barton & Green, 2001) PDDRS- Pervasive Developmental Disorders Rating Scale (Eaves, 1993)
SRS- The Social Responsiveness Scale (Constantino & Gruber, 2005) STAT-Screening Test for Autism in 2-yeat Olds (Stone & Ousley, 1997)
3.1.1 Graphical presentation of the content analysis of data from the medical context Table 1. Content analysis of data collected from the medical context
3.1.2 Textual presentation of the content analysis of data from the medical context The table above represents data (the particular instruments) collected from the medical
context of evaluating and diagnosing ASD. The structure and content of the table are based on the logic of identifying the main features of the instruments (coding), and then grouping the collected instruments by their common features. The main features of the instruments are derived both from the obvious structure and from the more sophisticated function of the instruments:
1. The starting point in coding/identifying the main features of each instrument was to understand the purpose of the collected instruments. The first column in the table (the first feature) is therefore coded as “purpose”. My intention was to find out whether all of these instruments have both evaluative and diagnostic purpose. By analysing their content, it became obvious that this is the case for some instruments, whereas others belong to either evaluative or diagnostic category. According to what their purpose is, the instruments are therefore coded into two sub-categories: evaluative and diagnostic.
2. Furthermore, I intended to find out, in understandable and accurate terms, how these instruments work and which form of measuring approach of the behavior they use. I have found two forms of measuring to be the most dominant: the direct (clinically observing the child), and indirect (using rating scales and questionnaires). In the table above this
common feature is coded as “form,” with two sub-categories “indirect” and “direct.”
3. I was further interested in distinguishing who are the sources of valuable information about the child that these different instruments are using. Therefore the next feature/the next column is coded as “source.” Here I have identified three different sources, and these are then coded in the table as three sub-categories: child, caregivers/teachers, and medical experts.
4. I was then interested in finding out which aspects of the behavior are these instruments actually measuring. The next feature/column in the table is therefore coded as “behavior”. I have identified five different aspects of behavior that the instruments are measuring:
social, emotional, cognitive, sensory and communicative, and these are coded as 5 sub- categories in the table.
5. Finally, I wanted to find out about the psychometric value of the chosen instruments – their validity and reliability. The last feature/the last column in the table is therefore coded as
“psychometric value.”
3.1.3 Theoretical perspectives in the selected instruments (medical context) The classification and understanding of autism is an ongoing process. In the 1990’s, diagnostic categorization of Pervasive Developmental Disorders (PDD) by the American Psychiatric Association (APA) and World Health Organisation (WHO) of the “autistic continuum” included ”Autistic Disorder, Asperger Disorder, Rett Disorder, and Childhood Disintegrative Disorder” (Luteijn et. al., 2000, p. 317). These disorders displayed common behaviors that were categorized as the triad of impairments (Luteijn et al., 2000).
A critical change in the conceptualization of the behavioral characteristics that will be measured in the future was found to be presented in theoretical frames of medical model, but since this change dates from the year 2014, it is yet unclear how this will change the future instruments, since none of the instruments that I have collected was made after this change. In 2014, in the new edition of the DSM-V, the autism is considered as a one-dimensional
category and does not include subcategories presented above and the behavior that was measured as triad of impairments was reduced to only two impairments: social
communication/interaction and restricted and repetitive interest (Adams & Matson, 2016, p.
7). The trait of imagination will be omitted from the diagnostic traits of future instruments for evaluation and diagnosing of ASD, and only the behavioral impairments will be measured (Adams & Matson, 2016). The effectiveness of these changes is still a topic of debate among experts from this field.
Even though other medical disciplines like neurology and genetics are trying to develop instruments that can accurately diagnose autism, the behavioristic approach is currently rooted within “developmental psychopathology perspective” (Klin, Saulinier, Tsatsanis, & Volkmar, 2013, p.772).
3.1.4 Purpose
The purpose column is showing whether a certain instrument is used for screening/evaluation for ASD, or for diagnostic purposes. From the total of 18 instruments that are presented in the table, six have the diagnostic purpose (ADI-R, ADOS-G, BFI, BSE-R, CARS, DISCO,);
twelve instruments have the screening purpose (ABC, ACD-DC, ASEBA, BISQUIT, BOS, CSBQ, 3-D, GARS-2, M-CHAT, PDDRS, STAT).
Although the “golden standard” of diagnostic instruments for ASD consists of combining the multiple sources (parent, and/or teacher report) together with direct observation and
diagnostic instruments, the reason for using screening instruments is of a practical nature
is to target the children at risk in general population, whereas targeted evaluation instruments, presented in the table above are used for children who showed warning signs in general assessing (Gardner, Campbell, Bradley, & Murphy, 2016). For the population of children that has been detected in general screening assessing, the thorough diagnostic evaluation is needed (Gardner et. al, 2016).
Even though assessment instruments cannot determine with certainty if a child has ASD, the psychometric values of instruments, such as reliability, are strong. This means that children that do score as potentially having ASD during the assessment process often get this diagnosis confirmed after the direct observation by the medical professionals (Gardner et al., 2016). The assessment instruments also have the purpose of delivering the preliminary results based only on the parents/teachers reports that strongly indicate the presence of ASD traits, without necessarily having to examine the child directly (Gardner et al., 2016). Instruments for diagnostic purpose measure behavioral traits for purely diagnostic purpose, in other words, they classify whether the behavior of the child is on the autistic spectrum (Gardner et al., 2016).
3.1.5 Form
The selected instruments can have a succinct (indirect), or comprehensive form (direct) (Constantino & Gruber, 2005). In the table above, instruments with the succinct/indirect form are: questionnaires (M-CHAT, SRS, SCBQ), checklists (ABC, CARS), rating scales (ACD- DC, ASEBA, BISQUIT, PDDRS), and interviews (3-DI, DISCO).
The common characteristics of these succinct instruments are that they do not take much time to fill out, and that the raters (persons who rate the child) are often persons who in fact are in most frequent contact with the child, for example, the child’s parents and teachers. However, the instruments with the succinct/indirect form can also be used by medical workers
(psychiatrists, psychologists) for the same purpose. When instruments for general screening are used, the raters are usually the child’s family members, whereas the instruments that are developed for targeted evaluation, such as diagnostic interviews, require an educated
investigator, since the answers are translated into a scaled coding system, which only trained professional can fill-out (Leekam, Libby, Wing, Gould, & Taylor, 2002).
The screening instruments are frequently included in the comprehensive diagnosing because they provide clinicians with the overall picture of a child’s functioning during a longer time.
The questionnaires and rating scales aim to measure the child’s functioning over the longer period, and the reactions in a variety of different situations that are not possible to simulate
during diagnostic observation (Leekam et al., 2002). For example, it is not possible to determine during the observation how the child reacts on the changes in routines, like going from home to school, eating habits and other important indicators of behavioral dysfunction.
The instruments with comprehensive form also include direct observation of the child by the medical professionals combined with questionnaires, interviews, or rating scales. These instruments are ADI-R, ADOS-G, BFI, BOS, BSE-R, GARS-2, STAT.
The comprehensive/direct form of diagnostic instruments includes direct observation of the child in a variety of different situations that are simulated in a clinical setting, in order to determine whether the child’s score will meet the diagnostic criteria (Klin et al., 2013). The possible simulated situations include activities like free play, directed play, cognitive tests, speech evaluation and the reaction of a child on the overall variety of situations and different people involved in the process (Klin et al., 2013).
3.1.6 Sources
The source column presents different sources (individuals) that the selected instruments include in the evaluation process. These sources may be defined as persons from child’s ecological environment (parents/teachers), or the clinical environment (trained medical professionals). In other words, the source column shows whether the information about the child is gathered in the ecological, or clinical setting, or by combining these two. From eighteen instruments, five instruments use all of the sources presented in the table (parents/
teachers/day-care workers, medical workers, and child). Instruments for comprehensive evaluation usually operate by collecting the data from either single or multiple sources, and from the environment that is either ecological (home, school) or clinical (different medical institutions where the evaluation occurs) (Powers, 2013, p. 820).
The variables from ecological environment can contribute to discovering strengths and needs of the child with ASD from and within his/her ecological environment, such as evaluation of family dynamics and interaction, evaluation of school system as well as including these sources to provide data on the functioning abilities of the child and the potentials that can rarely be observed in clinical conditions (Powers, 2013).
3.1.7 Behavior
Studying and understanding the etiology (the causality) behind ASD is very complex and includes a multidisciplinary approach (Allen, Robins & Decker, 2008). The cause of the
neurological disorders (Allen et al., 2008; Williams & Eaves, 2005). These targeted
behaviors can also be categorized as challenging behaviors (Leader & Mannion, 2016). There is an extensive domain of measurements that can determine whether a certain behavior can be described as challenging (Leader & Mannion, 2016). The behavior can be measured on molar and molecular levels (Powers, 2013). Molar level measures the predictability and duration of behavior, how long a certain behavior lasts, as well as the physical actions displayed during a certain behavior (Powers, 2013). The molecular assessment measures the ecological context of certain behaviors, such as how often and how intensively certain behaviors happen within different environments (Powers, 2013).
Evaluating the behavior by dividing it into different categories is not always a straightforward process, because these categories are mutually affected and connected, since there is no clear border between “cognitive, conative and affective domains of psychological functioning”
(Hobson, 2014, p. 233). Therefore the sub-categories in the table above, under behavior column should also be interpreted in this way. Different aspects of behavior that are presented in the table are measured by every instrument. The behaviour can be evaluated with a simple (succinct) form (with yes or no answer, rating some behavior on the scale of intensity and frequency), or it can be measured by richer description in the comprehensive form of diagnostic evaluation (diagnostic interviews, direct observation).
Social
Social behavior in ASD is characterized by the lack of need for socialization, as well as the difficulty to distinguish people from objects (Hobson, 2014). One of the ways to test the understanding of social situations in the comprehensive forms of evaluation is to test the concept of Theory of Mind (Lind & Williams, 2011).
Theory of Mind is the psychological concept that refers to one’s ability to understand the mental state of others and to distinguish them from their own (Lind & Williams, 2011). In the mid-1980s, Baron-Cohen (1985) established that this inability to understand the mental state of others is evident in individuals with ASD. The test was simple: in clinical conditions, the reactions of children on a play of two dolls were observed. The doll Sally represented the positive character and her task was to put the marble into the box and to leave the stage. After that, the other doll, named Naughty Anne took the marble and placed it in another box. The task for children was to answer in which box will Sally search for the marble when she comes back. Unlike typically developing children who knew that being away and not knowing that the marble was replaced, Sally will search for it in the first box, children with ASD failed to
pass the test successfully (Baron-Cohen, 1985). The explanation for why children with ASD fail this test is that they fail to understand that the doll Sally has a mind that differ from their own. They think that the doll knows what they know, and fail to recognize this essential difference in all other social interactions (Lind & Williams, 2011).
In some instruments the overall behavior is measured in the succinct assessment of social behavior. The CSBQ (Luteijn et al., 2000) and the SRS instruments (Constantino, 2000) both use questionnaires/rating scales to evaluate social behavior exclusively as a strong indicator for ASD traits.
The CSBQ instrument measures social behavior through five categories of interaction, including general problems in socialization and understanding of the other person’s perspectives. CSBQ also measures social behavior regardless of social interaction, such as acting out, or stereotypes (Luteijn et al., 2000). The SRS instrument measures the social behavior by collecting information from parents, and rating the results by grouping overall behavior into social behavior categories, as is described in CSQB instrument.
Emotional
Emotional detachment from siblings and parents, as well as general lack of empathy are characteristic signs of ASD and can be measured either in the direct observation or in the caregiver’s report. (Hobson, 2014) Inappropriate facial emotional expressions and reactions towards not only people but also situations are also often tested (Klin et al., 2013). One such example that can explain the inappropriate facial and social expression could be if the child, in anger, is refusing to engage in play with the siblings, but will instead look at a wall and laugh.
Emotional evaluation such as traditional personality test is not applicable to the ASD population, because of their difficulties in the area of linguistic and narrative skills (Klin et al., 2013). Emotional assessment gathers data through the visual psychological tests or analysing drawings in providing information about the mental and emotional development of a child (Klin et al., 2013).
Free and structured play, both in ecological (environmental) and clinical conditions, is a reliable method for making an overall emotional evaluation (Klin et al., 2013). For example, free play is the way child is using toys, or interacting with family members in ecological, or with medical professionals in clinical environment. Directed play is a sort of play in which a
instructed to be the doctor, or the patient, or instructing a child to assist the medical professional to make a cake by playing in the toy kitchen. Different activities in play can indicate emotional skills, such as symbolic (pretend) play that is often lacking in children with ASD (Hobson, 2014; Lind and Williams, 2011). In the use of instruments with a
comprehensive (direct) form like, for example, ADOS, the emotional evaluation of play consists of short series of different situations that involve both known (parents) and unknown (psychologists, or psychiatrists) persons (Klin et al., 2013). For example, it is common for children with ASD to have strong and negative emotional reactions when the environment around them changes (when they are instructed to go to another room, or if a new person approaches them). With this approach it is then possible to evaluate the adaptive behavior, such as emotional reaction of a child to different settings, toys, and persons (Klin et al., 2013).
Cognitive
“Children with severe pervasive developmental disorders display characteristics and appear to operate at the level of the arousal system, with little affective or cognitive processing”
(Williams & Eaves, 2005, p. 247). This is displayed in difficulties in understanding abstract and symbolic concepts, meaning that the cognitive abilities of individuals with ASD and real- life skills are very often disproportional (Williams & Eaves). For example, the child can learn to recognize a cat in the picture, but when the same child sees a real cat, she/he will not understand that it is also a cat. To find out how the child operates between learned and real- life situations, psychologists evaluate adaptive behavior, or the child’s ability to generalize their learning from the abstract to the concrete across different settings and contents (Klin et al., 2013).
Evaluation of cognitive functions is necessary to determine the level of cognitive functioning and learnt abilities, because mental deficiency is common in ASD (Klin et al., 2013). Unlike some other aspects of behavior (such as communication and social abilities) that can be evaluated easily by non-qualified raters, thorough cognitive tests “may require a highly structured, adult-directed approach within a very bare testing environment to yield the child’s
“best” performance” (Klin et al., 2013, p. 774). In practical terms, this means that instruments with the indirect form contain some questions that can address cognitive abilities, but the answers to these questions are grouped under the categories such as stereotyped behavior, communication, and social interaction. For example, the questions about object manipulation are connected to a stereotyped behavior and not to cognitive functioning, such as the case
with GARS 2 (Gilliam, 2006), whereas the PDDRS instrument is reducing behaviors to “three internal processes: arousal, affect, and cognition” (Williams & Eaves, 2005, p. 246)
Sensory
Sensory sensitivities are common in children with ASD (Baranek, Parham & Bodfish, 2013).
While no individual is the same, and different sensitivities can be challenging, the auditory sensitivities are most common in ASD population (Baranek et al., 2013). Sensory
impairments in children with ASD are related to numerous psychological dysfunctions such as depression, anxiety, empathy and social interactions (Hilton, 2011). They can also have a negative effect on learning abilities because repetitive stereotypical nature of ASD sensory defensiveness (involuntary motor movements) is preventing children from focusing on new learning experiences (Hilton, 2011).
Sensory sensitivities are not unique only for the ASD population. They are also common in other developmental disorders (Baranek et al., 2013). However, when evaluating ASD it is found that hyposensitivity (lack of reactions, or delayed reactions) to sensory stimuli is common in ASD, whereas hypersensitivities to the sensory stimuli are often present in other developmental disorders (Baranek et al., 2013, p. 832). The hyposensitivity to audio stimuli (not responding to name, or other loud sounds) is also typical for the population with ASD, and is one of the reasons why ASD is in the beginning often confused with hearing
impairment (Baranek et al., 2013).
When observing children during play, children with ASD can display significant interest in investigation of toys in unusual ways, for example they might show greater interest in lining up the toys in specific order, or spinning the wheels of the toy car for an unusually long time, rather than playing. Sensory problems are linked to this kind of behavior in play (Hilton, 2011). Problems with sensory regulation can also cause unusual body sensations and reactions (hand flapping, jumping, screaming), tactile sensitivity, and affect motor functioning by producing involuntary movements (Hilton, 2011).
The distinction between voluntary and involuntary movements is important for the evaluation because it is possible to detect and measure how often involuntary movements appear and how long they last (Hilton, 2011). The frequency and duration of involuntary movements are an indicator of the severity of ASD in the child, because the children who score higher on the autism spectrum usually display a higher presence and longer duration of involuntary
Communicative behavior/Communication
Speech delay or problems in communication are not present only in ASD. Generally, language delay occurs in 10-15 % of typically developing children and is also present in the population of children with developmental disorders other than ASD (Paul, 2013). What distinguishes ASD are certain aspects that are not always present in the other two previously mentioned groups of children. They include difficulties in verbal communication, pointing gestures, nonverbal communication, reduced responsiveness, atypical vocalizations, deficits in joint attention, lack of eye contact, pretend and imaginative play deficits (Paul, 2013, p.
799-800). Importance of encouraging non-verbal forms of expression is necessary, because it is estimated that only 23,8 % children with ASD aged 2-9 is verbally fluent, whereas 23,8 % uses short phrases that are not considered functional, 23,8% can pronounce single words, and the 28,6% do not use language at all (Anderson et al., 2007).
As it is clearly visible in table 1, communication is the common feature of every instrument.
This clearly illustrates that the lack of communication is one of the first warning signs of ASD presence. Assessment of communication skills can be done with the simple questionnaire with yes/no answers that can be used by professionals as well as by the caregivers. The questions address not only the words and their use, because children with ASD sometimes use words that are not appropriate to the situation, or repeat the same word that they heard - echolalia, but they also contain questions about pointing gestures and other forms of non-verbal communication (Anderson et al., 2007). The M-chat that has the purpose of evaluating for ASD, is based primarily on speech and communication evaluation (Robins, Fein, Barton &
Green, 2001). The advantage of M-chat is that it does not take long, and the questions are easy to understand and answer. System of rating the answers is 0-2-point scale. The questions in the M-Chat address overall communicative abilities including eye-gaze, pointing gestures, and words (Robins et al., 2001). The simplicity and high metrical value make this instrument very popular and one of the first indicators of early childhood ASD, since it evaluates children as young as 12 months old (Robins et al., 2001). Instruments that have comprehensive/direct form of observation often include presence of speech pathologist (Klin et al., 2013). A detailed evaluation of speech abilities is a reliable indicator for further development, quality of life and the potential cost of care for children with ASD (Anderson et al., 2007).
3.1.7 Psychometric value
ASD is a group of lifelong disorders that share a cluster of similar symptoms (Worley &
Matson, 2011). Constant improvement in standardization and revision of evaluation tools has
contributed to their high psychometric value and the need for revised version of previously used instruments (Worley & Matson, 2011). Currently, autism is “one of the most reliably diagnosed disorders in child psychiatry” (Lord & Corsello, 2013, p. 730). In the table we see that all the instruments have high metrical value from 0.75 in DISCO to r=0.94 in ABC.
However, the research shows there is a risk of false positives, meaning that there is a higher risk that a child who does not have ASD is diagnosed with it, than that the child who does have ASD goes undetected by diagnostic instruments (Lord & Corsello, 2013).
3.2 Data from music therapy context
After collecting the first set of data from the medical context, analysing their content and extracting the main and common features, I have searched for the instruments from music therapy context, with an idea to follow the same content classification. This was done in order to make sure that the same content and features are analysed from two different perspectives.
Since music therapy is not commonly used to evaluate and diagnose ASD (Bergmann, 2018), and since the number of available screening/diagnosing instruments is small, I have found it necessary to search for the relevant data in both research studies and theory. One advantage of utilizing the integrative literature review is that its methodology allows both research-based as well as theoretical-based literature to be included for the analysis (Cooper, 1989). Since the collected instruments from the music therapy field are few and very specific, I have chosen to describe each of them before presenting the interpretation of their main features.
3.2.1 Presentation of data from music therapy context
The data that is presented consists of seven chapter from the book S. Lindahl Jacobsen, E. G.
Waldon & G. Gattino (Eds.) (2018) Music therapy assessment: Theory, research and application and from two international survey studies on the assessment for ASD in music therapy.
Book chapters:
§ Waldon & Gattino (2018). “Assessment in music therapy: Introductory considerations”
§ Waldon, Lindahl Jacobsen & Gattino (2018). “Assessment in Music Therapy:
Psychometric and Theoretical Considerations”
§ Gattino, Lindahl Jacobsen & Storm, (2018). ”Music therapy assessment without tolls:
From the clinician’s perspective”
Instruments for assessment for ASD extracted from the book chapters:
§ Carpente (2018). “The Individual Music-Centered Assessment Profile for Neurodevelopmental Disorders”
§ Schumacher, Calvet & Reimer (2018). “The AQR Tool: Assessment of the Quality of Relationship”
§ Bergmann (2018). “The Music-Based Scale for Autism”
§ Wigram & Lindahl Jacobsen (2018). “Event-Based Analysis”
International survey studies:
1) Wilson & Smith (2000) ”Music Therapy Assessments in School Settings: A Preliminary Investigation”
2) Chase (2004) “Music Therapy Assessment for Children with Developmental Disabilities: A Survey Study”
Unlike the four designed tools that were extracted from the book chapters (in the table below they are coded as AQR, EBA, IMCAP-ND, MUSAD), tools that were extracted from the studies are not designed by individual therapists. They represent the population of music therapists that do assess children for ASD, but without using any of the designed music therapy tools. I decided to include these tools, because the literature indicates that a large percent of music therapists use self-created tools to assess for ASD (Carpente, Lindahl
Jacobsen & Storm, 2018; Chase, 2004; Wilson & Smith, 2000). Even though they do not have the exact design, they were coded by their common features, as these tools are essential in understanding how and why the 50% of music therapists are using them, instead of already existing, designed music ASD therapy assessment tools (Wilson & Smith, 2000). In the table below, they are coded as MTACD (Music therapy for children with developmental
disabilities) and MTASS (Music therapy in school settings).
3.3 Content analysis of the tools from the music therapy context
The data is coded, and its content is analysed following the same procedure that was used to analyse the data from the medical context:
1. Theory: What are the theoretical orientations that were found to be common 2. Purpose of the tools: whether the tool is used for assessing, or diagnosing ASD
3. Form: whether the tool is used for collecting the data from direct interaction, or indirectly through description of the child`s functioning from other sources
4. Sources: What sources (persons) are used to collect information on child´s functioning 5. Domains: What domains of behavior are measured
Coding of the instruments extracted from the selected literature presented above AQR (Schumacher et al., 2018)
EBA (Wigram & Lindahl Jacobsen, 2018) IMCAP-ND (Carpente, 2018)
MTACDD (Chase, 2004)
MTASS (Wilson & Smith, 2000) MUSAD (Bergmann, 2018)
3.3.1 Graphical presentation of the content from the data from music therapy context of assessment for ASD
Table 2. The content analysis of the data collected from music therapy context
3.3.2 Theoretical perspectives of the instruments from the music therapy context
The findings from analysing the content from the music therapy assessment tools in two of the studies (MTACDD, MTASS) indicate that half of the music therapists used self-created, experimenter-designed approaches that are in many cases used differently in each assessment (Wilson & Smith, 2000). Therefore, it is not clear whether there is a presence of continuity in theoretical orientation between music therapists that are assessing children for ASD.
However, by looking at individual music therapy instruments that are used for assessment and diagnostic purposes, the theoretical orientations are easier to detect. While the MUSAD
